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INVENTORY RECONCILIATION , PQFI N�`ZN <br /> QUARTERLY SUMMARY REPORT FORM t �P�V�CbS <br /> Facility Name: _L/iRL ,ENT, Tank i Size Product <br /> O U G #2 <br /> Facility Address: g(90 �Y/G[�D�t <br /> _ / /�//f <br /> �YI/1iJTG`GR G/a 953•�G; <br /> Telephone : 2 cl—B,z3 — P5/ <br /> Person Filing <br /> Report �14,,�IC,67-�9/-j= <br /> I hereby certify under penalty of perjury that all inventory variations for <br /> the above mentioned facility were within the allowable limits for this <br /> quarter. (No in Column 13 of the Inventory Reconciliation Sheet) <br /> Inventory variations exceeded the allowable limits for this quarter. I <br /> hereby certify under penalty of perjury that the source for the variation <br /> was not due to an unauthorized (leak) release. (Yes in Column 13 of the <br /> Inventory Reconciliation Sheet) <br /> List date, tank /, and amount for all variations that exceeded the <br /> allowable limits. <br /> Date Tank f Amount <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> Additional dates/amounts shall be continued on a separate sheet of <br /> paper and attached. <br /> If the source of the variation which. exceeded allowable limits was due to <br /> a leak the incident shall be reported to S .J .L. H . D . Environmental Health <br /> within 24 hours and an unauthorized release report submitted. <br /> The quarterly summary report shall be submitted within 15 days of the end of each <br /> quarter. <br /> 6QQuarter I - January --> March . / y$ <br /> Quarter 2 - April --> June <br /> Quarter 3 - July --> September <br /> Quarter 4 - October --) December <br /> Send to: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E . HazelL011 , P .O . Box 2009 <br /> Stockton , CA 95201 466-67b1 <br /> UGT 40 LO/86 <br />